Just finished a quick read of the white paper, and one glaring problem is that the HIV-reduction claims are based almost entirely on studies of African men.

Not only does the question arise about the significant differences in hygiene, nutritional status and behaviour between men in Africa and men in the U.S., I also have to wonder about the African studies themselves.

Did those studies adequately control for the undoubted differences in socieconomic status and behavior between circumcised and uncircumcised African men? It is likely that circumcised African men have better education, hygiene and access to health care resources than uncircumcised African men making the two populations difficult to compare, I would think.

They may be totally good, I don't know. But given that the HIV argument is being made on the basis of two entirely different populations (African vs. U.S.), I would take at least that part of their recommendations with a grain of salt.

Biologically, the studies are showing a reduction in risk for acquiring sexually transmitted infections in circumcised men.

The biology of African men and American/English/Russian/European men is the same as is the structure and infectivity of HIV and other infectious diseases found in the African countries where the studies were performed.

Furthermore, the mechanism by which circumcision is thought to reduced the risk of infection is biologically plausible.

What's more, the strength of the data needs to be taken into account. If the AAP were basing their recommendations on 1 study in the face of multiple other studies showing the opposite effect, then there would be a problem. However, many studies have demonstrated similar results.

The AAP has remained neutral on this topic for a long time (despite evidence in favor of circumcision). The fact that they changed their stance means that a high burden of evidence was met in order to tip their opinions.

I think it's perfectly fair to argue that the effect of circumcision may not be as high in the US as it is in Africa due to socioeconomic and education factors. However, for some to claim that there is no evidentiary basis that circumcision reduces the risk of infection is foolish. We are all humans and these studies were conducted in living, breathing, fucking, people.

Yes, biology is the same, and no one is arguing with that (as far as I can tell).

But the fact that circumcision decreases HIV infection rate in a population with a much higher exposure rate does not justify recommending it in a population with much lower exposure rate. There are huge cultural differences that really have to be taken into account, like what percent of men visit prostitutes and how often, sex workers' health status, beliefs about HIV prevention, etc. Men who do not engage in risky behaviors have exactly 0% chance of contracting HIV from those risky behaviors, so circumcision does them very little good. (Granted, there still is an extremely small risk of contracting it from a female partner who is not a sex worker.) You're much less likely to find these risky behaviors in the U.S. than you are in the countries in which these African studies have been conducted, so just the fact that risk is reduced is not justification within itself.

Thinking about it - and this is wild speculation - perhaps the reason why the pro-circumcision parties rely so much on the African studies is because they DO engage in risky behaviors, and so the benefits of circumcision are magnified compared to studies in Western countries where your average married man who maybe has an affair with a secretary but is otherwise monogamous may not see any statistically significant benefit at all. I mean, ARE there any definitive studies done on low-risk populations? Again, wild speculation.

I don't doubt that circumcision reduces the risk of transmission when having unprotected sex, but we all know it would be stupid to rely on circumcision to stop the spread of HIV. Is there any evidence suggesting that circumcision makes any significant difference in the risk of transmission when using a condom? I think we should focus more on getting people to use condoms instead of mutilating their genitals and possibly giving them the idea that they are now free to have unprotected sex without risking infection.

Based solely on biology, you could argue that cutting the male genetailia off completely is the best way to ensure that the boy does not contract HIV through sexual contact. Of course, it's ridiculous to prescribe that kind of irreversible action without considering what the risks and benefits actually are. rationalalternative was actually considering what the _real risks and benefits are. HIV is not a disease that is spread from person to person simply because we are human; it is spread based on our choices of sexual partners, condom usage, and intravenous drug use. The differences between the US and Africa are going to change the risk profile of living in these two places without being circumcised. Additionally, if you consider the methodology used in the Africa study, it wasn't a purely biological observation of the spread of HIV. It was an ex-post-facto examination of populations who engaged in risky sexual behavior. Considering that condom usage is much more prevalent in the US than Africa, condoms might be a much better prescription for the US because they will actually be used.

I would expand question 1 to ask is it beneficial within the population that the boy can reasonably be expected to be a part of when he's an adult? A boy born in the U.S. is extremely unlike to end up as a local in Africa or Southeast Asia where the highest infection rates are. Okay, maybe he's gay, but again, in the U.S. in this day and age, what are the chances that he's going to reach sexual maturity not knowing the extra risk involved with anal sex and thus failing to take the right precautions? The question isn't whether it's beneficial to any boy, anytime, anywhere - it's whether it's beneficial to this boy, right here, right now. Anyway, question 2 renders that moot.

That second part is the point that kills me. Okay, so there is increased risk of a urinary tract infection before age 1.

However, that does not seem likely to kill a person. And maybe once the person is an adult they can make their own choice -- but personally I find it very unlikely that any man is going to volunteer that part of his penis cut off.

The insistence that we circumcise children before they have the ability to object seems very much like religious indoctrination to me -- we know that they'll see it as bullshit later so we do it now.

Similarly amputating child's hands would probably cause health benefits, by reducing incidence of lung cancer, because it would make smoking more difficult.

This seems a bit extreme recommendation, considering there are probably other cheaper ways to get the same health benefits without the permanent harms.

Sexual, physical and psychological health and well being is more than avoiding rare infections.

Financial and religious interests may have an influence here. The paper makes recommendations about third party reimbursements of the procedure on the page e777.

These quotes from the paper make the recommendation sound irresponsible:

"Based on the data reviewed, it is
difficult, if not impossible, to adequately assess the total impact of
complications, because the data are
scant and inconsistent regarding the
severity of complications."

"Financial costs of care, emotional tolls, or the need for future
corrective surgery (with the attendant anesthetic risks, family stress,
and expense) are unknown."

One does have to be careful though of assuming that the population that isn't circumcised and the population that is, is 100% identical in every other way. Giving one group circumcision + education, just as one example, confounds the variables.

The extrapolation does cause me concern. But I think the randomized control studies were done intelligently. The circumcisions were given at the time of the study (for one of them at least). The men were told not to have sex for six weeks so that the folks who did have a circumcision could recover. But the guy I link to above disagrees with the validity.

I don't have a penis, but I suspect that if I did, I'd have to have a really good reason to agree to have a piece of skin cut off of it for the sake of a study. Maybe I would already be concerned about HIV. Maybe I would subconsciously be changing my own behaviors because of that. Then again, maybe I'd just be in it for the cash. Who knows what the participants' motivations were?

That's the problem I have with these studies. The only result seems to be convincing circumcised males that condoms aren't needed because HIV is less of a risk. We shouldn't be promoting this sort of thinking.

Edit: Posting this this one:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051968/
The fate of the foreskin. Charles Gaidner argues in the late 40s that the benefits fo circumcision are minimal, but complications from surgery lead to as many as 16 babies dying every year.

Statistician here. I don't know much about health issues, but "Step 2" in that blog post is completely off base. For starters, 1.18% and 2.49% are in no way "vanashingly small". Second, reporting relative risks is standard practice for comparing two relatively small percents. Appealing instead to "absolute differences", as the blog author suggests, would also lead us to conclude that second hand smoke has no meaningful effect on lung cancer. If the incidence of a disease is truly small, say .00001%, and we had a method of completely eliminating it, the blog author would claim that the cure was meaningless because it only reduced the disease incidence by .00001% in absolute terms.

To me, this points to an author with an axe to grind - just look at the other posts this guy has made at the bottom and it seems unlikely that he is going to change his mind regardless of what evidence he sees. I'll stick with the peer reviewed articles in this case - not because I have a large amount of faith in the peer review process, but because I have more faith in it than I do in rando bloggers who made up their mind a long time ago.

Upvoted, but there are some pitfalls here as well. Standard deviations aren't invariant under transformations, so what scale you look at your standard deviations on matters. Standard deviations are also inherently statistical; we care about practical differences as well, and what "pratical" means can only come from the subject matter. There are some efforts to frame "effect sizes" in the language of statistics, and capture a notion of what a "practical" differnce is without reference to subject matter - Cohen was a big proponent of this - but I've never bought into it.

Oh, for sure. But it's a hell of a lot more helpful seeing a mean and s.d. or a 95% confidence interval than seeing a simple average, etc.

As far as this study is concerned, though, I definitely have to agree with 90% of what the angry guy wrote about in his blog. While that one piece on absolute measurements was total B.S. the paper he referenced here is actually extremely informative.

We could also prevent 50% of testicular cancer by removing one testicle from each baby boy.

I would also look at the other side of the equation, if I were you: 6 square inches of erogenous tissue is in no way "vanishingly small", either, and it should be left to the owner of the penis to decide for himself whether the tradeoff is worth it.

You aren't completely off point, but the AIDS infection rates in Africa are off the charts compared to testicular cancer here. Your math is bad though because it completely ignores genetic predisposition to cancer, which makes cancer in one (possibly removed) testicle correlate with cancer in the other.

Circumcision has NOT protected Americans from acquiring the highest rate of HIV in the developed world, despite 80 percent of American-born males having undergone circumcision at birth.

This is the most blatantly-obvious counterpoint to the claims made by the AAP. HIV was spreading rapidly in the 1980's among circumcised gay men, and now it's spreading among circumcised straight men & women.

I would have really liked an explanation on how having an extra portion of skin on your penis makes it more likely to get aids. There's nothing logical about that. The only thing that makes sense is the prevention of infection, but that doesn't seem like a good reason by itself.

Don't forget HIV can be spread other ways. For instance, the Lower East Side of Vancouver has (or had) the highest HIV rate in the developed world. This is mostly do to intravenous drug users sharing their needles.

Is there data on permanently reducing pain tolerance? Also at what level do we incorporate the subjective value of your own anatomy and foreskin. Shouldn't surgical procedures on infants require a higher standard of medical necessity?

One can take issue with the journal article itself but to argue over NPR's second-hand coverage of the publication is pure idiocy.

The NPR article is mostly correct, except they take a stance that is deliberately sensational in saying there is a radical shift in policy for the American Academy of Pediatrics. This is not that accurate; as far as I am aware the AAP has always endorsed circumcision, just not as vocally as in this statement.

In saying this, I don't have a problem arguing over a layman article written by a skilled science journalist. The CNN article is better.

No. Beginning in 1999, with its last position paper, the AAP took no position on circumcision. The 1999 position stated that there was not enough evidence in favor of or against circumcision and that parents should make the decision based on religion, social standards and personal beliefs. But, according to the AAP for the last 13 years, there were no proven health benefits. As a parent with a son due in less than a month, I can tell you that this is pretty big shift.

Oh, thank you for this. In my brief search, I couldn't find any information regarding their previous stance. I just know that for a long time there has been evidence that there are some benefits to circumcision. Evidently it was not enough for the AAP to endorse the practice.

It didn't take more than a skim trough the article and its references to find it lacking in many ways. Most of its argument pro circumcision relates to the fact that it supposedly decrease chances of STD contamination, but the source articles supporting this conclusion are terribly flawed and cannot support such conclusion.

I'll summarize their methodology so you can take your own conclusions about its validity:

They went to poor countries in Africa with poor health, difficult access to health/medicines and high rate of STDs like HIV (none of the studies happened outside Africa, where conditions are much different, so that alone should be grounds to dis-consider those studies for policies outside Africa)

There they selected two groups of men, lets call them group A and group B:

Group A: all men were circumcised, what entailed a surgical procedure and several follow up visits to a doctor where those men were instructed about hygiene, STDs, and health stuff in general. Also those men were instructed not to have sex for several weeks.

Group B: none of the men were circumcised. Also, none of them were given any medical visits or health education. Those men didn't have any period of abstinence.

Then, surprisingly they found out that those men from group A (which were educated on STDs and had less sex because of the after surgery abstinence) had less STDs than those from group B, and concluded that circumcision must be the cause.

Your understanding of the study design is flawed. All of the men in "Group B" were given the same risk reduction counseling, education, and access to condoms as the circumcised men. They all received the same number of follow-up visits. In addition, the study was controlled for the "healing phase".

From the paper: "After the screen visit, which took place at month 1 (M1), the three follow-up visits took place at the end of M3, M12, and M21. The M3 visit was designed to study the possible impact of surgery on HIV acquisition as a result of sexual activity during the healing phase following circumcision or contamination during surgery. "

"At each of the four visits, each participant was invited to answer a face-to-face questionnaire, to provide a blood sample, and to have a genital examination and an individual counselling session....The counselling session (15–20 min) was delivered by a certified counsellor and focused on information about STIs in general and HIV in particular and on how to prevent the risk of infection....Condoms were provided in the waiting room of the investigation centre and were also provided by the counsellor."

Reading his comment I was baffled that researchers would overlook such basic variable control. This is much more logical, and what I suspected would actually be the case upon further evaluation of the article.

I find the problem with recommending circumcision as a way to lower the chance of contracting an STI is shortsighted. It's infinitely more effective to simply not engage in sexual activity at all. I recommend cutting off the entire penis. [/sarcasm]

The fact of the matter is that men a born with a penis that's designed to function a specific way, with a specific set of hardware. The fact that you can cut off half of it and still have it "function" is akin to pointing out how effective of a treatment lobotomy can be for certain types of behavior.

Aside from the point you raise about the differences in these two groups, which should naturally be taken into account, there's another side to any doctor recommending circumcision: money.

Knowing this, the most appalling aspect of the whole thing to me is that parents are, when you think about it, literally manipulated by their own sense of societal norms, questionable science, and sometimes even greedy or misinformed doctors into selling half of their newborn childrens' cocks to the highest bidder, and they don't even realize that someone else ran off with the cash.

Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it to warrant third-party payment for circumcision of male newborns.

All they're saying is they see no reason to ban it like Germany did since they now officially recognize the fact that there are indeed health benefits to doing it, which to me doesn't seem like anything new. Apparently the "ban" in Germany is a bit more complicated than I thought. Read the replies below (like this one or this one).

EDIT: Un-re-edited my edits.

EDIT2: Other people are way more informed about the AAP and their stance than I am. Make sure to read the other comments below.

PLEASE quit reporting comments simply because you disagree with them. Only report them if they actually break a rule. The report button is not an "I don't like this comment button."
Additionally, when reporting a link, it would be useful if you could message the mods to tell us why so that we don't have to go searching for a reason.
Thanks!

EDIT4: Phew, okay. One last thing that I think some people are misunderstanding about my contention with NPR's article. I'll start with another quote from the AAP policy statement:

Systematic evaluation of English-language peer-reviewed literature from
1995 through 2010 indicates that preventive health beneﬁts of elective
circumcision of male newborns outweigh the risks of the procedure.

The AAP is saying there are health benefits for those who want to circumcise their children, not that everyone should circumcise their children because of these health benefits, which, IMO, is what the NPR article is implying. Nowhere has the AAP said that those health benefits justified circumcising all males. The health benefits only outweigh the risks of the procedure; the health benefits do NOT outweigh not being circumcised.

the important point to note is the line "to warrant third-party payment for circumcision of male newborns" the purpose of this stance is to say that circumcision is not just a cosmetic procedure but that is has health benefits and insurance companies can not deny paying for it because it is a medical procedure not a cosmetic procedure. This report has nothing to do with saying whether you should or should not circumcise but that insurance companies should have to pay for it if the family chooses to do it

Precisely. That's the newsworthy part. The sensationalism comes in when NPR decided to downplay that aspect of the story and make it seem like the AAP was endorsing male circumcision across the board when they aren't.

It is not "banned" in Germany yet. A judge deemed it incompatible with current german law. Basically it was ruled that the babies right to bodily integrity overrides the right of parental determination and the right to free practice of religion of the parents. The ruling didnt evaluate possible health benefits yet, just made a ruling on circumcisions that arent medically indicated.

Thus, circumcision can be seen as a mistreatment. It isn't quite illegal, more of a grey zone. Doctors might get prosecuted now. Our parliament is in the process of writing a law that excludes medically unnecessary circumcision from the right to bodily integrity.

"Our parliament is in the process of writing a law that excludes medically unnecessary circumcision from the right to bodily integrity."

Why?

I don't see what is bad about this. Right to bodily integrity should be enforced in minors, if I said I wanted to tattoo my newborn in accordance with x random cult then I'd be told to fuck off and quite rightly. Why does it suddenly become okay form circumcision?

If people want their kids circumcised for religious reasons then given that a person can quite easily change religious stance later on, and that circumcision can be done later in life anyway I don't see any justification for doing it before consent can be given.

It's interesting what we consider ok and not ok with regards to children. I agree tattooing a child would be considered abuse, yet it's considered completely acceptable by most people to pierce a child's ears. Granted, circumcision falls more along the lines of a tattoo, but there's definitely some grey area in there, and the fact that there's evidence of some health benefit adds another variable. I wonder what will happen if the medical monitoring tattoos that seem to pop up from time to time ever become reality.

If religious people want to sacrifice someone they don't get to because we have issues with that shit. In other words moral considerations come first. It's a pretty moral consideration to ensure they admit that a child cannot join a religion or be modified in accordance with it. That's an adult decision and this kind of disgusting ignoring of such is why I cannot abide religion.

The reason it's illegal in Germany has absolutely nothing to do with whether the benefits outweigh the risks or not, and everything to do with patient autonomy, and, well, the exact same reason female circumcision (type IA even, the exat analog to most of the male ones) is illegal in pretty much the whole world. Which is a damn good reason, you see, human rights and all that.

I think this is such an idiotic stance for the AAP to take, it just shows how politicised and hypocritical they've become. There's plenty of good evidence to suggest that female circumcision has many, if not all of the same benefits the male one does. So they should either recommend against both on the grounds of medical fucking ethics (you know, the kind of thing they've sort of sworn to protect), or continue to fund and study towards the female counterpart, if they're so inclined to not care about that, and "only rely on the science for their recommendations" which seems to be their shield in this.

As a doctor this sickens me, for so many reasons. Firstly, because a recommendation like this does have far-reaching consequences (and you can tell by some people asking questions about it in this very thread); but most of all, because of the gross oversimplification of the topic. There are no benefits to circumcision that can't be taken advantage of by having it done later in life, when the patient can consent (reduced STD transmission rates), or when it's actually medically needed (phymosis and in some cases maybe even paraphymosis). They are being completely and utterly reckless on this. In a first world country like the US, where the AAP's members and public live and practise, there's certainly no "public health" concern to justify jumping over patient autonomy, as it has been considered (and with good reason) for some African countries.

Such a shame, the US had almost caught up in this very basic regard for human rights with the rest of the world. I do think this will set you guys back several years, if not decades.

TL;DR: removing baby girls' breast buds would more than likely have more benefits than risks in lives saved by the lack of breast cancer as well (and the ratio here is bound to be much, much lower), but we don't see the AAP recommending that, do we? This is not a matter of science, but one of human rights.

The crude relative risk of HIV infection among women reporting to have been circumcised versus not circumcised was 0.51 [95% CI 0.38<RR<0.70] The power (1 – ß) to detect this difference is 99%

It's not a perfect study, but it's one of very, very few; and it's heavy on the methodology. The results are pretty drastic, definitely comparable to the male counterpart.

Edit: For the complainers out there, IOnlyLurk found an even more solid study that controls most thinkable confounding factors. In a study meant to find the opposite, no less. It doesn't get any weirder than this.

As no biological mechanism seems
plausible, we conclude that it is due to
irreducible confounding

In other words - while their study seemed to show a lower relative risk, they couldn't control for a number of confounding factors and they themselves believe that the entirety of the results are because of them.

Though this article is heavy on the methodology it never states anything along the lines of "benefits outweigh the risks"

It is pretty clear that the correlation between decreased transmission of HIV and female circumcision is possible but in no way definite.

The article is quite emphatic on the very obvious and well known negative side effects of clitoridectomies such as increased incidence of hemorrhaging during child birth and increased infection during the procedure.

Indeed. If HIV were rampant in the US, bypassing patient autonomy would make sense from a public health standpoint, but we're nowhere near that desperate for a marginal statistical decline in transmission. The AAP report does not make that clear.

If HIV were rampant in the US, bypassing patient autonomy would make sense from a public health standpoint

Even then, it doesn't make a whole lot of sense- are we going to tell people it's ok to have unprotected sex if they've been circumcised? No. Is the chance of transmission while using a condom significantly different for circumcised men? No. So what's the point?

Use removing labia mucosa as an example then. Same benefits as removing foreskin mucosa. STD's are transmitted primarily through mucosal membranes, and keratinization of the glans (and removal of foreskin mucosa) are the primary reason for reduced infection. Trimming and exposing the vulvar mucosa would also reduce infection rates.

Just because there are benefits to something doesn't mean it should be done. Or done on children who can't make that choice for themselves. As parents we make medical decisions with our children's best interest in mind, and parents will try to use these "health benefits" as an excuse to circumcise. Even though there is even greater benefit to using condoms, abstinence, and monogomy.

Circumcision might be worth it if it eliminated infection risks. But it simply reduces your risk, and you still need to wear condoms. So what's the point? Seems weird to tell your kid that you had him circumcised to prevent std infections, and then tell them they better still be abstinent or wear condoms.

A surgery to permanently alter a very personal body part should not be trivialized because of supposed health benefits. As someone said previously, these procedures are things that can be decided on by consenting teenagers/adults who can decide they want the health benefits.

I'm not "pro" circ., I just don't think breast buds were a similar issue.

I don't think people would have it done if they didn't think they were doing their kid a favor, and as it becomes less common people will be less likely to do it. If it was normal to cut off seemingly trivial portions of the female genitals, then people would do that and defend it (women will opt to have their labia shortened for instance - maybe a mother who did that would want the same for her baby girl - and better to do it as an infant to avoid self-image issues and a traumatic surgery).

If you really want to eliminate STDs... remove the penis entirely. Then we can be sure to have the safe and sanitary artificial insemination for procreation purposes only. It would be a boon for both insurance and fertilization specialists. It would have the additional benefit of eliminating penetrative rape. It is win, win situation for all involved.

That's not all they're saying. That's all their press release said, but the actual spokesperson who headed the study said very clearly that it has definite health benefits that far outweigh any risks associated with it.

Did anyone else RTFA? Their official stance is that it is neither here nor there as to whether people should get their sons circumcised, but that it does offer some health benefits and should be covered by insurance companies for that reason. The actual people involved in the study, however, are saying it offers clear health benefits including greater resistance to infection by many STD's, which is pretty huge.

NPR should have refrained from using the language given by the unofficial statements of the people involved and stuck to the official results of the study itself, but don't just say they're being sensationalist when the only reason the official and unofficial stances differ is that the group in charge of the study would rather not deal with a bunch of controversy from anyone and can now say that they haven't thrown their support in favor of any particular side in the circumcision debate. It's a neutrality thing, officially at least. Don't confuse that with actual results though, this isn't like most scientific discoveries because it IS a politically and religiously charged subject and anyone making a statement in clear support of one side will lose any standing they have with the other side. In this case a lot of people who think circumcision is a terrible act of barbaric genital mutilation are going to be upset that someone said it has health benefits, but if they said it offers no health benefits at all and should be banned the huge number of religious people in this nation would react in a less-than-friendly way.

Wow. This subject is among the most sensitive that I have ever encountered on the Internet. Console wars, Israeli vs Palestinian, or Ron Paul vs traditional GOP has nothing on the touchiness of this topic.
Prepare for "dog-dicked" versus "the mutilated" style rhetoric.

Me too. Apparently, I'm the product of an abusive household, my dick mutilated by religious extremists, and my doctor & nonreligious parents should've been jailed. I fear I may be too old for foster care :(

It all boils down to the same basic human urges: People want to tell others what to do, and thereby have power over them. The argument of whether the child should make up their own minds is moot because children are more or less chattel in legal terms (medical decisions and otherwise) until they are 16-18 in most western countries.

It's most like the console war. A lot of people get hung up on console arguments because if they have a PS3, and the Xbox 360 is better, it means they made a bad decision and spent a lot of money on the wrong item. People have a hard time accepting that.

Nobody wants to have the wrong penis.

But I'm sick of seeing circumcision debates because who gives a shit. Be confident in your dick. There doesn't need to be a mythology about how filthy uncircumcised people are and how mutilated circumcised people are because most people get along fine with or without foreskin.

You're not wrong. This is THE most contentious topic on Reddit, way more of a big deal than child porn or pro/anti Israel. There seems to be a "Europe vs. America" thread running through the topic as well.

Circumcision ought to be left up to the kid, in most cases. It's a decision he's perfectly capable of making on his own when he reaches the age of majority. He can always go from being intact to being cut if he chooses, but going the other way is difficult and the reconstruction is imperfect.

On the hygiene side of things, I'm curious as to what circumcised males are comparing their experience when they say it's 'easier to keep clean'. Easier than what? Unless you're a male who was circumcised as an adult, I don't understand what your frame of reference is. Keeping an intact penis clean is no more involved or dramatic than keeping your underarm clean.

"I've had no problems with my mutilated genitals" is terrible justification for seeking to mutilate or supporting the mutilation of the genitals of newborns, and doesn't strike me as the sort of rational thought aspired to by most redditors. It's also something of a logical fallacy).

Unless there is some medical problem, the human body functions remarkably well without the need for surgical alteration.

On cancer

Yes, cutting off any portion of the body will ablate the risk of cancer in that portion of the body.

Is this something that you consider a reasonable measure to afford a 1 in 1000 protection?

Even if you did, it's important to note that 1.6% of men in Denmark are circumcised - yet rates of penile cancer are lower than in the US, where circumcision rates are far higher.

This study provides an excellent analysis of the 'penile cancer' circumcision myth, which appears to go all the way back to a poorly written publication from 1932.

On HPV being prevented by circumcision

This assertion likely stems from a spurious correlation involving the Jewish community. Subsequent peer-reviewed literature has shown this not to be accurate.

See this publication in the Journal of the American Medical Women's Association, which concludes that there is no difference between circumcision or intact men in their partners' cervical cancer.

There was this study in the Lancet in 2011 which appeared to find something, but their findings indicate that you need sixteen circumcisions to prevent a single infection, and it's important to understand that we're talking about a permanent surgical procedure to fix a problem that can be addressed through condom use and HPV vaccination in most locales.

First, those trials are suspect. Second, you're talking about a permanent surgical intervention to prevent something that can be handled by a barrier method of protection and proper education in most cases.

Cosmetics

Cosmetic perceptions are often about norms. Right now, in the U.S., circumcision is the norm. I don't hear these sorts of concerns in places like Denmark where circumcision is rare. (Anyone in Denmark care to chime in here?)

There are methodological issues with the studies done by Wiswell, including potential for selection bias and improper tratment of intact infants. Retrospective chart reviews are problematic because circumcision is not always recorded, and so some of the UTIs could have come from boys who were circucmised but not recorded as such. Further, breastfeeding may be a confounder.

It is possible that the surgical antiseptic used during the circumcision is responsible for the observed difference.

Girls have higher rates of UTI than intact boys, yet are afforded no special concern.

You'd need to circumcise about fifty infants to prevent one UTI, which can usually be cleared by antibiotics.

On Balanitis and Other Infections

Balanitis can in fact happen in boys with a foreskin, and according to this study, it may be more common in circumcised boys.

Previous findings indicating that balanitis might be more common in uncircumcised boys were not statistically significant and may therefore have been due to chance.

On Studies that Show No Difference in Sensitivity Between Intact and Cut Men, and on Claims That Circumsion Actually Improves Sexual Function in Men

Studies that fail to detect a difference in sensitivity often test only the glans of the penis. It makes sense that they don't pick up a difference; both intact and cut men have a glans!

The difference is in the foreskin, and it's tough to do an accurate comparison because cut men have nothing to compare to! They're missing that tissue entirely.

This study actually does seek to compare the foreskin to the closest thing cut males have - the scar tissue in that location - and substantial differences are found. The authors conclude that 'circumcision ablates the most sensitive part of the penis'.

Be careful when reading studies that claim improvement after circumcision. The most egregious offender is a guy named Morris. In specific, the "A 'snip' in time: what is the best age to circumcise?" article by Morris in 2012.

The problem with Morris is that many of the papers he cites addresses or includes males with phimosis - those 0.4/1,000 births who have foreskins so tight that it can cause erections and sex to be painful. Of course they report improved sexual function (or at least no change) after circumcision. But their experience is not reflective of the average anatomically intact male, who does not usually find sex painful!.

For this reading, these studies are extremely misleading in their conclusions.

The studies Morris cites to support his claim are:

Masood - that paper covered males with phimosis! And doesn't even address sexual function so much as it does satisfaction!

And Collins et al, which looked at 15 men and found no statistically significant difference. Well, with an N of 15, I'm not too shocked at that. Further, none of the questions in the inventory used address sensitivity. They just ask about 'overall satisfaction with sex life', sex drive, ejaculation... normal functional questions.

....Morris cites others, but I dont' want to belabor the point. The first two I dug into were confounded by Phimosis, and then he goes on to talk about studies done in Africa, which are problematic as I already mentioned.

This, coupled with the fact that it ablates the most sensitive part of the penis (referenced above), can lead to lower sensation and pleasure (referenced above), can lead to less pleasure in female partners (referenced above) leads me to conclude the following:

Infants should not be circumcised routinely. If we want to circumcise people, we ought to obtain consent to chop a portion of their penis off when they reach the age of majority. I suspect this will be difficult to do.

It's a very scientific post, and it lacks the more ethical/philosophical side. Specifically, circumcision is a violation of the right to bodily self-determination and, especially in Europe, the child's right to religious freedom. The violation of these rights are justified on the grounds of tradition, parents' religious freedom, and parents' right to raise their own children (also called parental responsibility). Of course, the last right is more of a duty towards providing the child with a safe and healthy upbringing.

Why these grounds are sufficient to violate such an elemental freedom as the right to self-determination really is beyond me. But I'm not a philosopher.

People are hotly debating the benefits/detriments but nobody up until you has said that what matters first is asking somebody's permission before cutting off part of their body. Holy shit we think third world countries have strange activities. What reasonable person doesn't agree that cutting off any part of your body without your permission is a violation of human rights?

And like you said if they want it done it can be, but there isn't really any going back. People are so selfish were lucky nothing even crazier or worse is a "normal custom". It's not that bad but it's the principle of being violated without permission that matters.

The problem is really that most of the supposed benefits are equal only to actually having good hygiene, and not having unprotected sex with untested strangers. The whole idea of getting circumcised just to lower your risk of getting HIV is friggin' insane, and the only reason they even promote it is because they're assuming you're gonna go and do the wrong thing.

And the reduction in UTIs, while it may sound like an impressive reduction is actually not a particularly great absolute risk reduction since your absolute risk of getting a UTI as a male is pretty low if you don't have any congenital abnormalities.

To be honest though I remember talking with parents regarding whether or not to circumcise their kids and most of the time people just did it so they'd look like their dad, and not because of any health things one way the other.

Personally I'd probably focus more on actually teaching parents about proper hygiene and stuff. The circumcisions that I had to see were pretty horrifying to see-especially when they couldn't get good local anesthesia-they have these little plastic tubs that they strap the babies down in so they can't move and then the metal cutting devices come out...and you're forcibly breaking the connections between the glans and the foreskin that are supposed to be intact until halfway through your childhood. Seriously, I doubt that many parents would really let their kids get circumcised if they had to actually witness the procedure but they almost never have to see it. Now I haven't ever witnessed a religious circumcision so I don't know if it's less horrifying or what, but it was seriously disturbing for me to see, and I also saw at least 3 kids who had botched circumcision jobs one way or the other (though I have to say leaving it too long is much better than leaving it too short since at least you can fix it pretty easily).

The UTI thing kinda cracks me up. Females have a much higher rate of UTIs than males. But let's worry about reducing that small rate. It isn't a miracle that my son has never had a UTI despite still having a foreskin. Guess what, my daughters haven't either. And if any of them had, there are treatments for it.

The 1-year probabilities of hospital admission for UTI were 1.88 per 1000 person-years of observation (83 cases up to end of follow-up) in the circumcised cohort and 7.02 per 1000 person-years (247 cases up to end of follow-up) in the uncircumcised cohort (p<0.0001).

In other words the risk of UTI is reduced by 0.514%, from 0.702% to 0.188%.

from the article:
"They're cherry-picking their evidence," she says. "They act as though there's this huge body of literature. It's all the same couple of studies that have been regurgitated and reprogrammed. Over the past 150 years, all kinds of medical benefits have been proposed as resulting from cutting off the foreskin, and they have all been disproven."

Ah, reddit's double standard on evidence never ceases to impress me. Research that goes against the hivemind? Suddenly everyone is an expert on the research or dismisses it out of hand. Research that support commonly held positions on reddit? Everyone is overjoyed and excited to use it to beat those who disagree into submission.

Confirmation bias at its most clear.

EDIT: To head off further angry comments about circumcision, I am not taking a position on circumcision. I'm saying the bulk of reddit comments/votes attack studies that don't support popular positions and glide by cheering studies that do. I'm pointing out confirmation bias, not the benefits/harms of circumcision.

Like this, or any other, ethical debate will be solved by scientific evidence. Point is that the positions are already taken, usually pre-determined by what happened in your own family, and people are just rehashing the same arguments over and over again.

Pretty much this. People usually argue the ethics of infant circumcision, rather than the benefits and detriments. While scientific papers- be they accurate or not- add fuel to the fire, nothing will change.

TL;DR - The different policies and ways that uncircumcised babies are treated relative to circumcised babies may be skewing statistical data.

I would like to follow up on this with an experience I had at my son's pediatricians office that really upset me. My wife and I together decided to not have our son circumcised, we considered it and in the end made the decision to not. I felt more strongly about it than she did.

When my son was 4 months old, he slept for 12 hours straight one night for the first time ever. This was a relatively long period for him to go without feeding and as a result may have gotten a little dehydrated. When this happens babies sometimes will pass urate crystals in urine which can cause pink streaks in diapers.
We were pretty sure he was fine and just a little dehydrated from sleeping so long but just to be sure we took him to the pediatrician. As soon as they saw that he was uncircumcised they said it was standard procedure to check and rule out a UTI. Before I knew what happened the nurse forcibly retracted his foreskin in order to clean it before performing a urinalysis. I was upset at the time that the nurse did this but the test came back negative for a UTI so I was happy about that ( I at no time believed it was a UTI, no fever, acting normal and good explanation for pink specks in diaper etc).

That night the tip of his penis became inflamed and swollen from being retracted. I was upset and called the pediatrician's office the next morning to tell them what happened and that the nurse that did it should be properly trained and alerted that it is not okay to do that.

A week and a half later he has a high fever and we take him in to the pediatrician again. Well guess what he tested positive for a UTI. Now I understand that it could be a coincidence but from the amount of inflammation he had we believe he contracted the UTI as a result of the forcibly retracted foreskin. We were later referred to a pediatric urologist who agreed that it very likely could have been the cause but no way to confirm for sure.
As a result of that whole incident he was referred for more tests and one such test required catheterization which is painful and repeated procedures can result in UTI's.

Thankfully he has not had any UTI's since and he is a happy healthy boy but I felt like in our situation the whole uncircumcised debate is almost a self fulfilling issue based on how if he was circumcised they would have not jumped to the UTI conclusion and the the misinformed nurse would not have caused the trauma that I truly believe caused the UTI.

The trouble is when this goes into the statistics it's not going to have an asterisk next to it explaining what happened. It will simply be uncircumcised = UTI, yup we were right...

Thanks for reading, I realize not all cases are like this but it makes me wonder how many others are.

EDIT: Posting this on the main thread as it got buried on a sub-thread before and I really want people to hear this. Also cleaned up formatting.

People who live in a circumcizing culture often don't know how to properly treat intact kids. Yes, foreskins should be allowed to retract naturally as boys age. Forcibly doing so before it can do so on its own actually rips apart skin.

UTI: for americans, who unjustifiably shower twice a day, I don't think hygiene is an issue. also, congenital phimosis is not an illness. maybe increase hygiene in developing countries, instead of cutting of foreskin as protection. don't just treat the symptoms.

Penile cancer: prevalence is actually lower in some uncircumcised majority countries. also risk is extremely low.

HIV: practice safe sex, use condoms. more cost-effective than having millions of children' foreskins cut off each year.

This thread is pretty heated, and this will probably end up at the bottom, but I have a question: does anyone know by what means circumcision is thought to reduce HIV risk? Because the studies seem to be statistical in nature, rather than based on determining the mechanism by which such a benefit might accrue, and (thereby) determining whether such a benefit could be had through less invasive means. I also understand that we were pretty sure cigarettes caused cancer long before we knew precisely how they did so, so is this where we are with circumcision?

As an adult male who underwent this treatment when I was 21 (medical reasons) I can safly say it sucks. However if there is evidence that it can lower some infection rates then there might be a medical reasons for arguing for it, however firstly there must be a risk reward analysis. Secondly is this treatment any better than other treatments at doing what is being claimed. I.e could we not achieve the same net result by using medication or other preventative measures before we advocate chopping bits off babies. I am a bit torn on this issue as I am really glad I had it done, but feel that it needs a strong body of evidence that this article simply does not provided in order to be a go to preventative treatment.

I am actually reading the white paper now. If they reference AFRICA one more fucking time. Why does the AMERICAN Association of Pediatrics make recommendation for American physicals based on data out of AFRICA?

I love this quote about Herpes Simplex Type 2:

One meta-analysis with good evidence found some protective effect of circumcision against HSV-2 of borderline statistical significance.

HIV infection risks are conditional, which means that they have to be multiplied by the chance of your sexual partner having HIV (compare Africa vs. Europe) and the chance of the condom being faulty. This means that the actual risk is much much lower depending on your geography and the quality of your protection.

If you want to use circumcision to justify having unprotected sex, it just becomes a matter of time before contracting HIV.

Your first and third points are well received but your second point is actually somewhat flawed.

The reason that the extra layer of skin hurts is that because once you've had sex, it does not act as a protector from getting in but as a protector from getting out. If you have sex and you've got the infected virus contacting the surface, the foreskin simply traps it there and provides a warm, moist environment which generally speaking would provide a much more suitable environment for them to thrive in.

I mean, to give it a suitable, if somewhat silly, analogy - it'd be like opening your door, letting a bear inside of your house, and then closing the door behind it vs. leaving the door open and weighing the chances that it eats all your food. Sure, it may wind up eating your food either way, but shutting the door behind significantly increases that chance because it has nowhere else to go.

There's been plenty of men who have been circumcised in adulthood and not noticed any negative impact on sensation. This argument seems to be based on speculation "if I lose it it'd be awful" which isn't a strong argument.

I have an issue with point 3. I was circumcised September of last year due to Phimosis. You say "guarantees...significantly diminished", and I can easily say that sex feels WAY better now than it ever did before. My Phimosis wasn't extreme (no glans constriction, just didn't have the ability to fully unsheathe) so I feel I have a fair opinion on both sides of the fence despite medical condition.

Exactly. All this article tells me is that parents need to do a better job cleaning their kids up when they change their diapers, and later on teaching them how to clean themselves.

I can't tell you how many times I've seen a parent change their son's poopy diaper and wiping from back-to-front – which, as most women know, is the fast track to a UTI. (Most UTI's are caused by fecal contamination of the urethra.) Parents need to be more aware of this, that's all.

All of these "risks" could be avoided by avoiding unprotected sex and simply cleaning your junk properly. As a society, are we really so lazy as to resort to sponsoring archaic forms of ritualistic genital mutilation simply because we're too lazy to slap on a condom or run a bar of soap over our crotches?

With admittedly a layman's knowledge of the science behind circumcision and its effects on men in general, I would just like to say that my penis was circumcised for nonreligious reasons and I notice that I have yet to get any infections in, on, or around it. Also girls seem to like circumcised over the alternative, but that is more of a societal issue.

I never understood how people could have the tip of their penis exposed and pressed against underwear/pants all day..that would be excruciatingly painful for me, I can only guess the nerves on the head of the penis die or become desensitized?

I'm willing to bet that removing the clitoral hood and labia would also reduce transmission of std's while not preventing orgasm. But that would be a felony. Can anyone share data on the subject? I've seen studies suggesting this but do not have the time to track them down at the moment.

As a circumcised male, I really wish I had my foreskin. I suspect my circumcision was botched, because as I went through puberty and my penis grew, I didn't have enough foreskin and my skin literally tore to accommodate enough room for my erect penis to be, well, erect. I don't think I've experienced so much pain in my life. Many days I'd walk around with what looked like a mini donut on the tip of my dick because what was left of my foreskin was swollen from the skin being so irritated with it tearing and whatnot. I don't wish that upon anyone.

Just imagine bleeding from your dick when you're 11ish and going through puberty. Like seriously I had no idea what the fuck was happening to my body.

My son is 2, uncircumcised, has never had a UTI or any kind of problems with his penis. I do not pull his foreskin back for any reason or attempt to clean under it, as I was properly educated to by doctors when I had him. I think part of the problem of foreskins are people who are misinformed about them and try to clean under it and cause tears and pain.

When he is old enough I will teach him and encourage proper safe sex practices, abstinence only education will only harm the teens and young adults who are sexually active or going to be.

If he wants to get a circumsicion when he is old enough to decide for himself that's something he wants, than he has my support for that as well.

I really just can't in good faith support cutting off any future son's foreskin when he is an infant. If my hypothetical son is interested in getting it done when he is older and old enough to understand the procedure, I would support him in it. But doing this to babies just seems wrong to me.

Physician with a son here. Here's how I read this (text is the first four guideline findings, emphasis mine)

Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.

Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.

Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.

Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

What this means to me: slightly more pediatric residents will be getting trained on circumcision (because the risk:benefit justifies access). I should be careful in how I phrase my advise and keep it objective (duh?), but it ultimately doesn't matter enough for me to try too hard to persuade a family in the US one way or another.

I have a child who is uncircumcised, and if you clean properly and teach him proper hygiene, then you won't have any problems. He hasn't had any urinary tract infections or anything like that. We made the decision not to have him cut after a few of our friends did and had to go back to the hospital after the doctors botched it.
Just in case he feels like it's something he needs to do, my wife and I have put money into an account to pay for one once he gets old enough to decided whether or not he wants it done.

these "benefits" were known before and they are all bullshit. UTIs are rare to begin with and easily treatable, if girls can be taught hygiene so can uncircumcised boys. As far as prevention of STDs, circumcision doesn't even come close to allowing for unprotected sex so it's a moot point.
What is a fact however is that the body of a person is being violated and a sensitive, sexually functional part of the body is destroyed.

Lastly there is a tremendous status quo bias here. Imagine if someone wanted to remove earlobes from babies. What health benefits would need to be PROVEN effective for us to allow routine earlobe removal? I am guessing much more than we have. People defend it because they don't want to feel cheated or like monsters for what they did to their child.

Lastly ask any male with a normal, healthy foreskin if he would like to get rid of it... It's inconceivable. It's a useful, functional sex organ for masturbation and intercourse. Keeps the gland of the penis internal and moist and soft.

I was circumcised at 23, 2 years ago, and I dont get the big deal. Sex still feels great, I last longer, dont find it any harder to come, I notice literally no difference at all, I dont miss my foreskin. I dont get all the arguing, both are fine.